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Dangerous Rashes in Kids Heather Murphy-Lavoie, MD OBJECTIVES Review and understand how to recognize a sick kid Understand the

he pathophysiology and treatment of dangerous disease states which present with rash in the pediatric population HOW TO RECOGNIZE A SICK CHILD Pediatric Assessment Triangle

Rapid, global assessment using only visual and auditory clues (appearance, work of breathing, circulation) Appearance: TICLS Tone, Interactiveness, Consolability, Look/gaze, Speech/cry Work of breathing: Abnormal airway sounds, abnormal positioning, retractions, nasal flaring Circulation: Pale, mottled, cyanotic

Allows for rapid categorization: Stable vs. Sick Obviously sick patient must be treated & diagnosed at same time IF THEY ARE OBVIOUSLY SICK THEY NEED PROMPT TREATMENT REGARDLESS OF THE MORPHOLOGY OF RASH.

Classic Exanthems and other viral rashes Historically, six infectious exanthems were described: measles (rubeola), scarlet fever, rubella, Dukes (4th disease), erythema infectiosum (fifths disease), and roseola. The majority of childhood exanthems are nonspecific and cannot be accurately assigned to a discrete etiologic diagnosis. These exanthems are typically self-limiting and resolve spontaneously within a week. Measles Measles is rarely seen in developed countries due to widespread use of the MMR vaccine. However, measles continues to be problematic in developing countries. In 1997 it remained the 6th leading cause of death worldwide, and it is still a leading cause of blindness in children in Africa. The causative agent is paramyxovirus. Measles has an incubation period of 7 - 12 days and occurs most commonly in winter and spring. Its contagious 3 days prior to, and up to 5 days following, the onset of the rash. Presenting signs and symptoms include a prodrome of gradually increasing high fever (often > 104 degrees Fahrenheit), coryza, dry hacking cough, headache, and an impressive bilateral conjunctivitis. This prodrome occurs 2 - 4 days prior to the appearance of the rash. Kopliks spots may appear on the buccal mucosa opposite the 2nd molars during this time. While not always seen, Kopliks spots are pathognomonic of measles. After approximately 3 days, an erythematous, nonpruritic, maculopapular rash appears, first behind the ears and at the hairline, and then spreads inferiorly.

As the rash spreads to involve the trunk and extremities, the discrete macules coalesce. After approximately one week, the rash fades. Diagnosis is typically clinical, however, laboratory diagnosis can be accomplished by serologic assays if necessary. Treatment of measles is primarily supportive. Administration of vitamin A is associated with a reduction in the risk of mortality and a reduction in the post-measles pneumonia complications in children less than two years old. (Yang 2005) Potential complications include blindness secondary to corneal ulcerations, pneumonia, laryngotracheobronchitis, otitis media, myocarditis and encephalitis. Mortality ranges from 0.3% in developed countries to 26% in undeveloped countries. Scarlet fever Scarlet fever is a toxin-mediated condition characterized by fever, oral mucosa involvement, and a rash. It usually occurs in children < ten years old. Scarlet fever is most often associated with streptococcal tonsillopharyngitis, although it can be seen after other streptococcal infections. The incidence is highest late fall to late winter. Scarlet fever has an incubation period of 2 - 5 days prior to the appearance of the rash. Presenting symptoms include: abrupt onset of fever, headache, malaise, odynophagia, and occasional vomiting and abdominal pain. These findings are followed by an enanthem consisting of bright red oral mucosa, palatal petechiae (Forschheimer spots - punctuate erythematous macules on the palate and uvula), and a strawberry tongue. A rash follows the onset of fever by 1 - 2 days and has been described as generalized erythroderma with scattered pinpoint, erythematous blanching papules, giving the rash a sandpaper-like texture. Capillary fragility causes petechiae in the flexural surfaces (Pastias lines), and facial flushing with circumoral pallor is often apparent. The palms and soles are typically spared. The exanthem typically resolves in 5 days, followed by post-exanthematous desquamation, especially on the palms and soles, after about 2 weeks. Diagnosis is typically

clinical, but can be confirmed by streptococcus-positive culture of local infection such as pharynx. Penicillin remains the treatment of choice of streptococcal pharyngitis in order to prevent local suppurative complications and acute rheumatic fever. Complications are rare, but include: acute rheumatic fever, acute glomerulonephritis, sepsis, pneumonia, pericarditis, hepatitis, otitis media, meningitis, and toxic shock syndrome. Untreated the mortality for scarlet fever is 15-20% but is reduced to <1% with appropriate antibiotics.

Rheumatic Fever Up to 3% of untreated Group A streptococcal pharyngitis will be complicated by rheumatic fever. Judicious use of penicillin has made this entity a relatively rare complication of pharyngitis or scarlet fever. Diagnosis requires 2 major criteria or 1 major and 2 minor criteria with evidence of a recent group A streptococcal infection. The Major Jones criteria include: carditis (40% - 60% of cases), migratory polyarthritis (75% of cases), Sydenhams chorea, subcutaneous nodules, and erythema marginatum (< 10% of cases). The Minor Jones criteria include: fever, arthralgias, elevated acute phase reactants, and prolonged PR interval. Treatment includes: penicillin or erythromycin for 10 days, salicylates, and in cases of severe carditis prednisone may also be helpful. Mortality is 2-5%. Toxic Shock Syndrome Staphylococcal toxic shock syndrome (TSS) is a potentially lethal disease which is characterized by acute onset fever, generalized erythroderma, and hypotension. It is due to a localized infection or colonization with a toxin-producing strain of S. aureus. While TSS is classically associated with menstruating women using tampons, recent changes in the

manufacturing and use of tampons has resulted in a decrease in incidence of menstrualassociated TSS. Currently up to 45% of cases are associated with sources other than tampons, such as infected wounds. Symptoms characteristically begin with high fever, malaise, chills, headache, myalgias, vomiting, and diarrhea. Hypotension and multi-organ involvement rapidly follow. Cutaneous symptoms include a diffuse, blanching, macular eruption which begins on the trunk and spreads to the extremities, followed by desquamation, particularly on the palms and soles. Mucous membranes are involved and may include erythema and ulcerations of the pharyngeal, oral, conjunctival, or vaginal mucosa. Potential complications include refractory shock, acute renal failure, neurologic symptoms, DIC, ARDS, and death. Diagnosis is usually clinical, however occasionally S. aureus may be isolated from localized infection. The treatment of TSS includes hemodynamic stabilization of shock and multiorgan failure. Additionally, the physician should attempt to identify and treat the infection with local drainage if needed or removal of tampon and antistaphylococcal antibiotics.

Rubella Rubella is a relatively mild illness caused by the rubivirus, and is characterized by a maculopapular rash. Rubella has an incubation period of 12 - 23 days, with a period of infectivity which extends from a few days before until 7 days after rash onset. Rubella occurs most commonly in later winter and early spring. The prodrome, if present, is mild and consists of malaise, pharyngitis, cough, low-grade fever, coryza, and a headache. A faint pink/red maculopapular rash then appears, first on the face, then rapidly spreading inferiorly. The rash typically resolves in 3 - 4 days. While the prodrome commonly occurs in adults and adolescents

1 - 5 days prior to rash onset , it is often absent in younger children. Other clinical findings include: posterior cervical and occipital lymphadenopathy, Forchheimers spots, arthralgias, and neutropenia. Diagnosis is clinical, however, serologic tests can be used for confirmation as needed. Treatment for rubella is supportive and patients should be counseled to avoid pregnant women. Potential complications of rubella include arthritis, encephalitis, thrombocytopenia, and congenital rubella syndrome when maternal exposure occurs in the first trimester. Mortality is less than one in 10000 for typical pediatric cases; however, cases of the congenital rubella syndrome can cause birth defects including: hearing loss, congenital heart disease, mental retardation, visual deficits, and numerous other neurologic and endocrine disorders including the blue berry muffin syndrome. Erythema infectiosum Erythema infectiosum, otherwise known as fifth disease, is caused by human parvovirus B19, and typically affects school-aged children. It has an incubation period of 1 - 2 weeks and occurs more frequently in winter and spring. Children with this virus typically feel well, however, about 10% of patients experience a prodrome consisting of low grade fever, headache, sore throat, malaise, myalgias, and coryza. This prodrome is followed by a bright, fiery red macular rash across the cheeks, giving the child a slapped cheek or sunburned appearance. This rash lasts 1 - 4 days, and progresses into a more generalized, lacy and reticular pattern, most prominent on the extensor surfaces of the extremities. The rash may then wax and wane over the following month, increasing in intensity with various stimuli. Once the rash appears, these children are no longer infectious. Diagnosis is clinical, but serologic tests are available for confirmation if necessary. Treatment of erythema infectiosum is usually supportive, but is important to advise parents to keep the ill children away from pregnant women and those with

hemolytic anemias. High-risk groups may be treated with intravenous immune globulins. Complications are rare but include symmetric arthritis of the hands, wrists, or knees, and intrauterine infection and fetal death if the infection occurs during the first half of pregnancy. Patients with hemolytic anemias and hemoglobinopathies (particularly sickle cell disease) are prone to transient aplastic crisis when infected with parvovirus. Roseola Roseola is the most common viral exanthem in children < 3 years. . The causative agents of roseola are human herpes virus 6 and 7. Roseola has an incubation period of 5 - 15 days. It is characterized by a high fever of 2 - 5 days duration in an otherwise well-appearing child, followed by resolution of the fever and development of a blanching, evanescent, pink maculopapular exanthem on the neck and trunk. The rash typically lasts approximately 1 -2 days. Other associated signs and symptoms include: mild coryza, cough, otits media, headache, periorbital edema and posterior cervical lymphadenopathy. Erythematous papules called Nagayamas spots may be seen on the mucosa of the soft palate and uvula. Diagnosis is clinical and treatment is typically supportive. This is usually a benign and self-limited disease. Febrile seizures are a common complication. Other potential complications are very uncommon but include thrombocytopenia, hepatitis, and encephalitis. Varicella (Chickenpox) The incidence of varicella has dropped 90% in the last 20 years, with the introduction and routine use of childhood vaccinations. Chickenpox, caused by the varicella zoster virus, is highly contagious and has a peak incidence in late winter and spring. It is seen primarily in children from 2 - 8 years of age. After an incubation period of 10 - 21 days, the prodrome

begins with malaise, headache, low-grade fever, cough, coryza, anorexia, and sore throat. After approximately 1 -2 days of prodrome the characteristic skin eruption begins on the trunk and spreads, over the following week, to the face (including mucous membranes) and extremities (sparing the palms and soles). The lesions begin as red macules that quickly progress to discrete vesicles on an erythematous base. The vesicles (commonly described as dew drops on a rose petal) rapidly evolve into pustules which umbilicate and crust over in 5 - 10 days. The lesions are intensely puritic. A characteristic feature of chickenpox is crops of lesions, which are simultaneously present in all stages of development at the same time. The lesions disappear in 7 - 10 days. The period of infectivity of varicella is from several days prior to the onset of the rash until all the lesions completely crust over. Diagnosis is typically clinical, but a Tzanck preparation demonstrating multinucleated giant cells or other viral assays can be used for confirmation if the diagnosis is unclear. In most cases, appropriate management of chickenpox is focused on symptomatic relief of constitutional symptoms and pruritis, as well as prevention of secondary infection. Wet dressing, soothing baths, and calamine lotion with oral antihistamines may provide symptomatic relief of pruritis. Acyclovir may be effective in treating varicella and preventing systemic complications in immunocompromised children. The role of acyclovir in otherwise healthy children infected with chicken pox remains unclear. In normal, immunocompetent children, systemic symptoms are mild and serious complications are rare. A common complication of varicella includes bacterial superinfection of the skin lesions. If present, secondary bacterial infections should be treated with oral antibiotics directed at Staphylococcus aureus or group A beta-hemolytic streptococci, such as cephalexin, amoxicillin/clavulanate, or dicloxacillin. If the secondary infection is very localized and minor,

topical mupirocin may also be an option. Other potential complications include pneumonia, vasculitis, and encephalitis. Immunocompromised children, and those patients receiving chronic steroid treatment, are more prone to suffer extensive skin eruptions, varicella pneumonia, and severe constitutional symptoms. Lastly, maternal infection during the first trimester can result in congenital varicella syndrome, while perinatal maternal infection can result in disseminated herpes in the neonate. Perinatal varicella carries up to a 30% mortality; therefore, every effort should be made to avoid exposure of pregnant women to children with chickenpox. Enteroviral Exanthems Enteroviral exanthems comprise a collection of conditions caused by picornaviruses, including coxsackievirus, echovirus, and enterovirus. These are the most common summertime exanthems. Disease expression ranges from exanthems (most commonly seen in younger children), to aseptic meningitis (older children). The characteristic exanthem is typically morbiliform. Associated symptoms include upper respiratory symptoms, conjunctivitis, fever, vomiting, and diarrhea. Complications of this assorted group of viral infections include pericarditis, myocarditis, pleurodynia, parotitis, hepatitis, pancreatitis, and encephalitis. One particular enteroviral exanthem caused by coxsackie virus A16 is hand-foot-andmouth disease, characterized by oral vesicles followed by vesicles on the hands and feet. Handfoot-and-mouth disease has an incubation period of 3 - 6 days. These patients are highly contagious from 2 days before to 2 days after onset of the eruptions. Hand-foot-and-mouth disease has a brief prodrome of low-grade fever, malaise, anorexia, and odynophagia. The oral lesions begin as small red macules that evolve into vesicles ranging from 2 mm 2 cm in diameter. These vesicles then rapidly rupture, leaving painful erosions. Children often refuse to

eat or drink secondary to the pain; thus, dehydration is a potential complication. The lesions of the hands and feet begin as macules and papules, then evolve into flat-topped, elliptical vesicles with an erythematous base. The diaper area may also be affected in infants. Diagnosis is clinical and treatment is symptomatic. Topical agents such as anesthetic mouth wash may provide relief from painful oral ulcers. Rare complications include myocarditis, pneumonia, meningoencephalitis, aseptic meningitis and, as with many of these childhood exanthems, infection during the first trimester of pregnancy may result in spontaneous abortion. Epstein-Barr Epstein-Barr virus is the causative pathogen of infectious mononucleosis. Although asymptomatic in young children, adolescents and young adults often experience fever, congestion, odynophagia, adenopathy, hepatosplenomegaly and peripheral or periorbital edema after an incubation period of one to two months. The associated morbiliform erythematous exanthem can be found on the trunk and extremities in 5% of patients. Furthermore, 80% - 90% of patient with mononucleosis develop a rash if given amoxicillin or ampicillin. Mono-spot testing can be used for diagnosis, however it is unreliable in children < 4 years, or if the symptoms have been present for < 5 days. Approximately 0.1% - 0.5% of cases are complicated by spontaneous splenic rupture. Avoid contact sports for 4 weeks. Treatment of infectious mononucleosis is supportive. Erysipelas Erysipelas is a distinctive form of cellulitis affecting mainly infants, young children and the elderly. It is caused by Group A streptococci. Erysipelas affects only the upper dermis, whereas cellulitis also involves the deep dermis and subcutaneous fat. Erysipelas occurs most

commonly on the face or lower extremities, although any area of the body may be affected. The involved skin appears as a warm, tender, shiny, erythematous plaque with raised and sharply demarcated boarders. Rapid spread is the rule and blistering of the lesion can occur. Associated signs and symptoms include high fever, chills and anorexia. Diagnosis is clinical. Treatment with penicillin plus clindamycin is recommended and is associated with better outcomes than mono-therapy. Henoch-Schonlein Purpura Henoch-Schonlein purpura (HSP) is a small-vessel vasculitis characterized by purpuric rash, abdominal pain, arthritis, and hematuria usually seen in children between 3 - 10 years of age. HSP is often preceded by an upper respiratory infection or drug exposure. The pathophysiology of HSP involves deposition of immunoglobulin A, C3, and immune complexes onto small vessels, leading to systemic inflammation. The classic triad associated with HSP comprises purpura, abdominal pain, and arthritis. The purpura are palpable and most commonly found in a symmetric distribution over the buttocks and extensor surfaces of the legs. The abdominal pain is colicky and may be associated with nausea, vomiting, diarrhea, bloody stools, or intussusception. Hematuria occurs in 10% - 20% of cases; however, less than 1% of children eventually develop end-stage renal disease. The diagnosis of HSP is clinical, however blood count, coagulation studies, chemistry, and urine should be collected to exclude other diagnoses and to evaluate renal function. HSP is a self-limited illness and treatment is supportive. Nonsteroidal anti-inflammatory drugs may be used to reduce pain in the joints and soft tissue. Patients should be hospitalized if complications develop, such as significant bleeding, intussusceptions, or renal failure.

Meningococcemia Infection with Neisseria meningitides, a gram-negative intracellular diplococcus, has a predilection for adolescents and children < 4 years old. Meningococcemia is invariably fatal without treatment. Moreover, mortality remains at 10% 20% even with immediate therapy. Patients appear ill, febrile, in shock, with mental status changes and a rash that develops within 24 hours of toxicity. The rash is initially erythematous and maculopapular (begins on extremities) which then spreads and becomes petechial. This is, also, a vasculitic rash with palpable petechiae. Early in the illness, it can be mistaken for RMSF. Treatment for both is mandatory for any diagnostic uncertainty. Diagnosis is confirmed by Gram stain and blood and / or cerebrospinal fluid (CSF) cultures. Remember, a Gram stain of a meningococcal skin lesion is more sensitive (72%) than a Gram stain of the CSF (22%). Lumbar puncture, in cases of meningitis (85% of cases of meningococcemia), classically shows a leukocytosis with neutrophil predominance, elevated protein, and low glucose. Ceftriaxone is first line therapy, but vancomycin should be added in cases of diagnostic uncertainty to cover resistant streptococcal meningitis. Dexamethasone (0.15mg/kg) has been shown to reduce neurological sequelae if administered early (prior to antibiotics, if possible). Prophylaxis with rifampin (600mg po BID) is recommended for close contacts (single dose ciprofloxacin 500mg or intramuscular ceftriaxone 125mg -250mg are alternatives). Vaccination is now recommended routinely for all 11-18 year olds. Complications include disseminated intravascular coagulation (DIC), ARDS, renal failure, multi-system organ failure, and adrenal hemorrhage (Waterhouse-Friderichsen Syndrome). Mortality is 5-30% depending on the promptness of therapy.

Staphylococcal scalded skin syndrome Staphyloccocal scaled skin syndrome (SSSS) is a potentially life-threatening, toxinmediated disease manifested by tender blistering and widespread desquamation. It usually occurs in children < 5 years of age. SSSS is postulated to be due to lack of antibodies against the toxin, and reduced excretion of the toxin as compared to adults. The etiologic agent is exotoxin-producing Staphylococcus aureus of phage group 2. Initial staphylococcal infection typically involves the nasopharynx, umbilicus, urinary tract, cutaneous wounds, conjunctiva, or blood. Symptoms of SSSS include sudden onset of fever and irritability, followed by slight diffuse erythema (resembling a sunburn) and cutaneous tenderness (infant does not want to be held). Symptoms initially affect the perioral and periorbital regions, the neck, axilla, and groin. This is followed by the exfoliative phase, which involves crusting around the mouth and eyes. Flaccid bullae develop. Gentle traction on the affected skin results in epidermal separation (Nikolskys sign), leaving a shiny, moist, red surface. The mucous membranes are not involved. In the newborn, the entire skin surface may be involved (Ritters disease). The diagnosis is

clinical. Complications may include sepsis and respiratory distress. Treatment is directed toward elimination of active S. aureus infection, which eradicates the toxin production. Patients are typically treated with a beta-lactamase penicillin or clindamycin. Although antibiotics are recommended, it is unclear whether they measurably alter disease course. Hospitalization for fluid/electrolyte management and for supportive skin care is indicated for most patients. Kawasaki Disease

Kawasaki disease (KD) is an acute, febrile, multi-system illness of unknown etiology, which causes widespread vasculitis in young children. The incidence of KD peaks at about 9 11 months, with approximately 80% of affected children being < 5 years of age. The diagnosis of KD disease can be made if 5 of the following criteria are met: Fever > 39 degrees Celcius for > 5 days and 4 of the following: Bilateral conjunctival injection without exudates Erythema of the oropharynx, lips with fissures, or strawberry tongue Acute cervical lymphadenopathy Polymorphous erythematous exanthem (rash may be morbiliform, scarlantiniform or maculopapular and may have plaques or target lesions) Edema of the palms and soles with subsequent desquamation 2 - 3 weeks after onset of illness Patients with only four of these symptoms may be diagnosed if coronary aneurysms are found on echocardiogram. The most important clinical complication is coronary artery aneurysms, which may lead to myocardial ischemia and sudden death. Other complications are less common and include hydrops of the gallbladder, diarrhea, small bowel obstruction, arthritis, cystitis, peri- or myocarditis, valvulitis, and aseptic meningitis. Management of KD is directed at reducing the risk of coronary artery aneurysm and thrombosis. This is achieved with high dose aspirin and IVIG. All children with KD should be hospitalized with supportive care. Rocky Mountain Spotted Fever (RMSF) This is a tick borne illness (Rickettsia rickettsi) that occurs mostly in the Eastern 2/3 of the United States. The incidence in the United States in 2002 was 3.8 cases / million people.

Unfortunately, only about 50% of patients can recall a tick bite.

The erythematous

maculopapular rash classically begins on the wrists and ankles and spreads over the body. Early, the rash will present as reddish macules that blanch, only to become petechial and purpuric later. This is a vasculitic rash with palpable petechiae. In up to 20% of cases the rash is absent (spotless fever). Regardless, the patient will usually be febrile and toxic. The diagnosis is clinical!! Do not wait for confirmatory antibody tests to begin treatment. Serologic testing will be negative in the acute period. Lumbar puncture will usually be less dramatic than in

meningococcal meningitis showing a leukocytosis with about 25% neutrophils, elevated protein, and low to normal glucose. The mortality is approximately 30% if untreated; this decreases to 5% with prompt antibiotic therapy. Doxycycline is the drug of choice in all non-pregnant patients, even children. Pregnant patients may be treated with chloramphenicol. Permanent neurological deficits persist in 15% of cases despite optimized care.

Disease Measles

Season Winter spring Fall spring

Morphology Erythematous confluent maculopapular

Scarlet fever

Rubella

Erythema infectiosum Roseola Varicella

Late winter and early spring Winter and spring Spring Later winter and early

Distribution Associated findings Begins at hairline, Kopliks spots, high spreads inferiorly fever, 3 Cs cough, coryza, conjunctivitis Generalized Begins on face Pastias lines, erythema with and upper trunk exudative pharyngitis, sandpaper and spreads abdominal pain, texture inferiorly rheumatic fever Rose-pink Begins on face Lymphadenopathy, maculopapular and spreads arthralgias inferiorly Slapped cheek, Erythematous Rash waxes and wanes lacy reticular cheeks, reticular over several weeks, rash extremities arthritis, aplastic crisis Rose-pink Neck and trunk Lymphadenopathy, maculopapular febrile seizures Vesicles on an Begins on face Pruritis, varicella erythematous and trunk and zoster

spring Coxsackievirus Late summer or early fall

base, crusts Ellipitcal vesicles on erythematous base, oral vesicles and erosions Morbilliform Morbilliform

spreads centripetally Mouth, hands, feet

Adenovirus EBV

Winter spring Anytime

Trunk and extremities Generalized

Upper respiratory symptoms Hepatosplenomegaly, lymphadenopathy, pharyngitis

TAKE HOME POINTS Rashes with fever deserve extra attention, especially if fever has been present for more than 5 days. Palpable petechiae and fever are associated with many types of bacteremia and should receive intravenous antibiotics immediately. Many pediatric exanthems are benign for children but potentially devastating to immunocompromised and pregnant individuals. Patients who are moderately to critically ill with evidence of rash should receive targeted empirical therapy Staphylococcal scaled skin syndrome and toxic shock syndrome require antistaphylococcal antibiotics, hemodynamic stabilization, and supportive skin care

References

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